Factors associated with skilled birth attendance in 37 low-income and middle-income countries: a secondary analysis of nationally representative, individual-level data.

BACKGROUND: Progress on skilled birth attendance (SBA) has been very uneven across low-income and middle-income countries (LMICs). There is scant empirical evidence on the role of fundamental development processes in explaining differences in SBA outcomes across world regions over time in these settings. We therefore aimed to estimate how these processes have contributed to observed changes in SBA across Latin America and the Caribbean, South Asia, Southeast Asia, and sub-Saharan Africa. METHODS: We pooled all available Demographic and Health Survey (DHS) rounds that contained detailed birth attendance information. The compiled data covers about 1·1 million births (1·1 million female individuals) from 103 DHS rounds in 37 countries. We estimated the determinants of SBA using multivariable regression techniques and Oaxaca-Blinder decompositions for different world regions and time periods (1990s, 2000s, and 2010s). FINDINGS: We show that progress in SBA is associated with improvements in terms of household-level wealth, mothers' education, urbanisation, contraceptive knowledge, and proxies of female empowerment. Furthermore, we show that changes in the underlying relationship between SBA and specific development indicators (wealth, education, and rural residence status) have further contributed to the observed rise in SBA across LMICs. Our findings further suggest that certain determinants of improvements in SBA are region-specific (eg, importance of rural residence status in sub-Saharan Africa), whereas some of the studied processes (eg, poverty, maternal education, and urbanisation) have become less predictive for the uptake of SBA over time. INTERPRETATION: Although substantial progress has been made in increasing SBA rates over the past three decades across LMICs, further efforts for continued progress are still needed to achieve international targets on SBA as part of the Sustainable Development Goals, the Every Newborn Action Plan, and the Ending Preventable Maternal Mortality initiative. According to our findings, these efforts can include general policies (eg, female empowerment) and region-specific policies (eg, poverty reduction programmes in Southeast Asia). FUNDING: Bernhard Nocht Institute for Tropical Medicine. TRANSLATIONS: For the French and Indonesian translations of the abstract see Supplementary Materials section.

Vaccine hesitancy and trust in sub-Saharan Africa.

Lack of trust is a primary reason behind the global rise in vaccine hesitancy. Existing research on the trust-vaccine hesitancy nexus has almost exclusively focused on COVID-19 with the vast majority of studies examining industrialized countries. In this study, we investigated the influence of trust in different policy-relevant actors (government, science, media, pharmaceutical companies, society) on vaccine hesitancy for recently available vaccines related to polio and HPV which we benchmark against a COVID-19 vaccine. Leveraging unique primary data on 5203 individuals from six countries (Ghana, Kenya, Nigeria, South Africa, Tanzania, and Uganda), we showed that individuals' trust in the government and society are key predictors of vaccine hesitancy. Furthermore, we demonstrated that these relationships are remarkably stable across vaccine, disease, and country contexts.

Who shares fake news on social media? Evidence from vaccines and infertility claims in sub-Saharan Africa.

The widespread dissemination of misinformation on social media is a serious threat to global health. To a large extent, it is still unclear who actually shares health-related misinformation deliberately and accidentally. We conducted a large-scale online survey among 5,307 Facebook users in six sub-Saharan African countries, in which we collected information on sharing of fake news and truth discernment. We estimate the magnitude and determinants of deliberate and accidental sharing of misinformation related to three vaccines (HPV, polio, and COVID-19). In an OLS framework we relate the actual sharing of fake news to several socioeconomic characteristics (age, gender, employment status, education), social media consumption, personality factors and vaccine-related characteristics while controlling for country and vaccine-specific effects. We first show that actual sharing rates of fake news articles are substantially higher than those reported from developed countries and that most of the sharing occurs accidentally. Second, we reveal that the determinants of deliberate vs. accidental sharing differ. While deliberate sharing is related to being older and risk-loving, accidental sharing is associated with being older, male, and high levels of trust in institutions. Lastly, we demonstrate that the determinants of sharing differ by the adopted measure (intentions vs. actual sharing) which underscores the limitations of commonly used intention-based measures to derive insights about actual fake news sharing behaviour.

Automated wearable cameras for improving recall of diet and time use in Uganda: a cross-sectional feasibility study.

BACKGROUND: Traditional recall approaches of data collection for assessing dietary intake and time use are prone to recall bias. Studies in high- and middle-income countries show that automated wearable cameras are a promising method for collecting objective health behavior data and may improve study participants' recall of foods consumed and daily activities performed. This study aimed to evaluate the feasibility of using automated wearable cameras in rural Eastern Ugandan to collect dietary and time use data. METHODS: Mothers of young children (n = 211) wore an automated wearable camera on 2 non-consecutive days while continuing their usual activities. The day after wearing the camera, participants' dietary diversity and time use was assessed using an image-assisted recall. Their experiences of the method were assessed via a questionnaire. RESULTS: Most study participants reported their experiences with the automated wearable camera and image-assisted recall to be good (36%) or very good (56%) and would participate in a similar study in the future (97%). None of the eight study withdrawals could be definitively attributed to the camera. Fifteen percent of data was lost due to device malfunction, and twelve percent of the images were "uncodable" due to insufficient lighting. Processing and analyzing the images were labor-intensive, time-consuming, and prone to human error. Half (53%) of participants had difficulty interpreting the images captured by the camera. CONCLUSIONS: Using an automated wearable camera in rural Eastern Uganda was feasible, although improvements are needed to overcome the challenges common to rural, low-income country contexts and reduce the burdens posed on both participants and researchers. To improve the quality of data obtained, future automated wearable camera-based image assisted recall studies should use a structured data format to reduce image coding time; electronically code the data in the field, as an output of the image review process, to eliminate ex post facto data entry; and, ideally, use computer-assisted personal interviews software to ensure completion and reduce errors. In-depth formative work in partnership with key local stakeholders (e.g., researchers from low-income countries, representatives from government and/or other institutional review boards, and community representatives and local leaders) is also needed to identify practical approaches to ensuring that the ethical rights of automated wearable camera study participants in low-income countries are adequately protected.

Can mHealth campaigns improve CCT outcomes? Experimental evidence from sms-nudges in Indonesia.

Employing a clustered RCT this paper examines the short-term impact of a 12-month mHealth BCC campaign on health practices & outcomes among CCT beneficiaries in Indonesia. Our analysis reveals that the intervention led to substantial improvements in maternal health behavior (postnatal care, child vaccinations, hygiene practices) & outcomes (anemia rates). Adopting a heterogeneous treatment effect framework, we further show that improvements in maternal hygiene practices and anemia rates are closely linked to health knowledge gained by mothers through the sms campaign. In contrast, we provide suggestive evidence that improvements in other health indicators are more likely to be related to the reminder and nudge components of the intervention.

Validation of an Automated Wearable Camera-Based Image-Assisted Recall Method and the 24-h Recall Method for Assessing Women's Time Allocation in a Nutritionally Vulnerable Population: The Case of Rural Uganda.

Accurate data are essential for investigating relationships between maternal time-use patterns and nutritional outcomes. The 24 h recall (24HR) has traditionally been used to collect time-use data, however, automated wearable cameras (AWCs) with an image-assisted recall (IAR) may reduce recall bias. This study aimed to evaluate their concurrent criterion validity for assessing women's time use in rural Eastern Ugandan. Women's (n = 211) time allocations estimated via the AWC-IAR and 24HR methods were compared with direct observation (criterion method) using the Bland-Altman limits of agreement (LOA) method of analysis and Cronbach's coefficient alpha (time allocation) or Cohen's κ (concurrent activities). Systematic bias varied from 1 min (domestic chores) to 226 min (caregiving) for 24HR and 1 min (own production) to 109 min (socializing) for AWC-IAR. The LOAs were within 2 h for employment, own production, and self-care for 24HR and AWC-IAR but exceeded 11 h (24HR) and 9 h (AWC-IAR) for caregiving and socializing. The LOAs were within four concurrent activities for 24HR (-1.1 to 3.7) and AWC-IAR (-3.2 to 3.2). Cronbach's alpha for time allocation ranged from 0.1728 (socializing) to 0.8056 (own production) for 24HR and 0.2270 (socializing) to 0.7938 (own production) for AWC-IAR. For assessing women's time allocations at the population level, the 24HR and AWC-IAR methods are accurate and reliable for employment, own production, and domestic chores but poor for caregiving and socializing. The results of this study suggest the need to revisit previously published research investigating the associations between women's time allocations and nutrition outcomes.

How (not) to mobilize health workers in the fight against vaccine hesitancy: Experimental evidence from Germany's AstraZeneca controversy.

BACKGROUND: COVID-19 vaccine hesistancy is a serious policy issue in Germany as vaccinations have stagnated at low levels compared to most other European countries. In this context, we study whether and how health workers can be leveraged to promote the COVID-19 vaccination campaign. METHODS: We employed an information experiment with health workers in Germany to quantify how access to information related to (i) AstraZeneca's vaccine safety, (ii) misinformation, (iii) individual health risks, and (iv) public health risks can sway health workers' recommendations for any of the following vaccines: AstraZeneca, Johnson & Johnson, Moderna, Pfizer/BioNTech, Sinopharm, and Sputnik-V. The information experiment was conducted as a randomized controlled trial with four treatment arms and was embedded in an online survey. RESULTS: Health workers reduce their willingness to recommend four out of six vaccines once they learn about different statements of European and German health authorities with respect to the safety of the AstraZeneca vaccine. Consistent with the discussion on AstraZeneca's safety focusing on possible side effects among younger women, we find that especially female health workers become less likely to recommend the majority of COVID-19 vaccines. Lastly, we show that health workers vaccine recommendations are not affected by misinformation and appeals to individual or public health. CONCLUSION: In order to mobilize health workers in the fight against vaccine hesitancy, information campaigns need to be tailor-made for the target audience. In particular, health workers react to different types of information than the general public. As with the general public, we provide suggestive evidence that health workers require unambigious messages from drug authorities in order to support vaccination efforts. We believe that a more coordinated and coherent approach of public authorities can reduce the amount of mixed signals that health workers receive and therefore contribute to health workers engagement in the outroll of mass COVID-19 vaccination campaigns. TRIAL REGISTRATION: The trial was registered retrospectively with the repository of the Open Science Framework (OSF) under the number osf.io/qa4n2 .

Validation of a life-logging wearable camera method and the 24-h diet recall method for assessing maternal and child dietary diversity.

Accurate and timely data are essential for identifying populations at risk for undernutrition due to poor-quality diets, for implementing appropriate interventions and for evaluating change. Life-logging wearable cameras (LLWC) have been used to prospectively capture food/beverage consumed by adults in high-income countries. This study aimed to evaluate the concurrent criterion validity, for assessing maternal and child dietary diversity scores (DDS), of a LLWC-based image-assisted recall (IAR) and 24-h recall (24HR). Direct observation was the criterion method. Food/beverage consumption of rural Eastern Ugandan mothers and their 12-23-month-old child (n 211) was assessed, for the same day for each method, and the IAR and 24HR DDS were compared with the weighed food record DDS using the Bland-Altman limits of agreement (LOA) method of analysis and Cohen's κ. The relative bias was low for the 24HR (-0·1801 for mothers; -0·1358 for children) and the IAR (0·1227 for mothers; 0·1104 for children), but the LOA were wide (-1·6615 to 1·3012 and -1·6883 to 1·4167 for mothers and children via 24HR, respectively; -2·1322 to 1·8868 and -1·7130 to 1·4921 for mothers and children via IAR, respectively). Cohen's κ, for DDS via 24HR and IAR, was 0·68 and 0·59, respectively, for mothers, and 0·60 and 0·59, respectively, for children. Both the 24HR and IAR provide an accurate estimate of median dietary diversity, for mothers and their young child, but non-differential measurement error would attenuate associations between DDS and outcomes, thereby under-estimating the true associations between DDS - where estimated via 24HR or IAR - and outcomes measured.